Advances in the study of KRAS in brain arteriovenous malformation.

Background：Brain arteriovenous malformation (bAVM) is an abnormal vascular mass with disordered arteriovenous connection. Endothelial KRAS mutation is common in bAVM. In vivo studies have demonstrated that mutations of KRAS in somatic cells can induce bAVM-like angiogenesis, suggesting that KRAS gene may play a key role in the development and progression of bAVM. Summary：In this article, we will provide a comprehensive review of action mechanisms of KRAS mutations in the development of bAVM and summarize potential targeting drugs for KRAS mutations in bAVM somatic cells. Key Message: KRAS mutation in human brain endothelial cells is a key driver in the pathogenesis of sporadic cerebral arteriovenous malformations. It is of great clinical importance to explore and summarize the changes in the signaling pathway induced by KRAS mutation, which may provide additional targets for the treatment of sporadic bAVM development.

CT Hyperdense Artery Sign and the Effect of Alteplase in Endovascular Thrombectomy after Acute Stroke.

Background Recent evidence suggests that presence of an intracranial arterial thrombus with a hyperdense artery sign (HAS) at noncontrast CT (NCCT) is associated with better response to intravenous alteplase. Patients with HAS may benefit more from combined intravenous alteplase and endovascular treatment (EVT). Purpose To investigate whether HAS at NCCT modifies the treatment effect of adding intravenous alteplase on clinical outcome in patients with acute large-vessel occlusion undergoing EVT. Materials and Methods This study is a secondary analysis of a prospective randomized trial (Direct Intra-arterial thrombectomy in order to Revascularize AIS patients with large-vessel occlusion Efficiently in Chinese Tertiary hospitals: A Multicenter randomized clinical Trial [DIRECT-MT]), which compared adding alteplase to EVT versus EVT alone in participants with acute large-vessel occlusion between February 2018 and July 2019. Participants with catheter angiograms and adequate NCCT for HAS evaluation were included. HAS was determined visually by two independent investigators at baseline NCCT. Treatment effect of intravenous alteplase administration according to presence of HAS on the primary clinical outcome (modified Rankin Scale [mRS] score at 90 days) and secondary and safety outcomes were assessed using adjusted multivariable regression models. Results Among 633 included participants (356 men [56%]; median age, 69 years), HAS was observed in 283 participants (45%): 142 of 313 participants (45%) in the EVT-only group and 141 of 320 participants (44%) in the group with added intravenous alteplase. Treatment-by-HAS interaction was observed for the primary outcome (P < .001), whereby a shift in favor of better outcomes with added intravenous alteplase occurred in participants with HAS (adjusted odds ratio [OR]: 1.82; 95% CI: 1.18, 2.79), while an adverse effect was seen in participants without HAS (adjusted OR: 0.62; 95% CI: 0.42, 0.91). This also held true for three secondary outcomes (excellent outcome [mRS score of 0-1 at 90 days], P = .005; good outcome [mRS score of 0-2 at 90 days], P = .008; final successful reperfusion, P = .04) in the adjusted models. Conclusion After acute ischemic stroke, presence of hyperdense artery sign (HAS) at baseline noncontrast CT indicated better outcomes when alteplase was added to endovascular treatment, but adding alteplase to endovascular treatment resulted in worse outcomes in participants without HAS. Clinical trial registration no. NCT03469206 © RSNA, 2022 Online supplemental material is available for this article.

H2S Attenuates LPS-Induced Acute Lung Injury by Reducing Oxidative/Nitrative Stress and Inflammation.

BACKGROUND: Hydrogen sulfide (H2S), known as the third endogenous gaseous transmitter, has received increasing attention because of its diverse effects, including angiogenesis, vascular relaxation and myocardial protection.We aimed to investigate the role of H2S in oxidative/nitrative stress and inflammation in acute lung injury (ALI) induced by endotoxemia. METHODS: Male ICR mice were divided in six groups: (1) Control group; (2) GYY4137treatment group; (3) L-NAME treatment group; (4) lipopolysaccharide (LPS) treatment group; (5) LPS with GYY4137 treatment group; and (6) LPS with L-NAME treatment group. The lungs were analysed by histology, NO production in the mouse lungs determined by modified Griess (Sigma-Aldrich) reaction, cytokine levels utilizing commercialkits, and protein abundance by Western blotting. RESULTS: GYY4137, a slowly-releasing H2S donor, improved the histopathological changes in the lungs of endotoxemic mice. Treatment with NG-nitro-L-arginine methyl ester (L-NAME), a nitric oxide synthase (NOS) inhibitor, increased anti-oxidant biomarkers such as thetotal antioxidant capacity (T-AOC) and theactivities of catalase (CAT) and superoxide dismutase (SOD) but decreased a marker of peroxynitrite (ONOO-) action and 3-nitrotyrosine (3-NT) in endotoxemic lung. L-NAME administration also suppressed inflammation in endotoxemic lung, as evidenced by the decreased pulmonary levels of interleukin (IL)-6, IL-8, and myeloperoxidase (MPO) and the increased level of anti-inflammatory cytokine IL-10. GYY4137 treatment reversed endotoxin-induced oxidative/nitrative stress, as evidenced by a decrease in malondialdehyde (MDA), hydrogenperoxide (H2O2) and 3-NT and an increase in the antioxidant biomarker ratio of reduced/oxidized glutathione(GSH/GSSG ratio) and T-AOC, CAT and SOD activity. GYY4137 also attenuated endotoxin-induced lung inflammation. Moreover, treatment with GYY4137 inhibited inducible NOS (iNOS) expression and nitric oxide (NO) production in the endotoxemia lung. CONCLUSIONS: GYY4137 conferred protection against acute endotoxemia-associated lung injury, which may have beendue to the anti-oxidant, anti-nitrative and anti-inflammatory properties of GYY4137. The present findings warrant further exploration of the clinical applicability of H2S in the prevention and treatment of ALI.

Resveratrol alleviates endotoxemia-associated adrenal insufficiency by suppressing oxidative/nitrative stress.

We have recently demonstrated that endotoxin causes oxidative stress and overproduction of nitric oxide in adrenal glands, thereby leading to adrenocortical insufficiency. The aim of this study is to investigate the effects of resveratrol, a natural plant polyphenol with anti-oxidant and anti-nitrative properties, on endotoxemia-associated adrenocortical insufficiency. Resveratrol was administered immediately before injection of lipopolysaccharide (LPS). Twenty four hours later, the adrenocorticotropic hormone (ACTH) stimulation tests was been performed to measure the plasma corticosterone level and the adrenal gland tissues were collected for histopathologic examination, and determination of malondialdehyde (MDA), total antioxidant capacity (T-AOC), superoxide dismutase (SOD) activity, catalase (CAT) activity, inducible nitric oxide synthase (iNOS) expression, nitric oxide (NO) and peroxynitrite production. Treatment with resveratrol significantly inhibited endotoxemia-induced iNOS expression, NO production, and peroxynitrite formation and also attenuated LPS-induced oxidative stress in the adrenal gland, as evidenced by the decrease of pro-oxidant biomarker (MDA), and the increases of anti-oxidant biomarkers (T-AOC, CAT and SOD activity). H&E staining demonstrated that administration of LPS resulted in increased into the adrenal gland. H&E-stained sections of adrenal glands demonstrated signs of leukocyte infiltration and hemorrhage during endotoxemia, which were significantly improved by resveratrol treatment. In addition, resveratrol reversed the LPS-induced downregulation of ACTH receptor and silent information regulator 1 (SIRT1) in adrenal gland, as well as adrenocortical hyporesponsiveness to ACTH. Resveratrol exerts protective effects against endotoxemia-associated adrenocortical insufficiency by suppressing oxidative/nitrative stress. These findings support the potential for resveratrol as a possible pharmacological agent to improve adrenocortical insufficiency resulting from oxidative/nitrative damage.

Enterprise stent for the treatment of symptomatic intracranial atherosclerotic stenosis: an initial experience of 44 patients.

BACKGROUND: Wingspan stenting for the treatment of complex intracranial atherosclerotic stenosis (ICAS), i.e., that involving tortuous vascular pathways, long (>15 mm) lesions or arterial bifurcations, has a relatively high risk of complications. This retrospective study assessed the safety and efficacy of undersized balloon angioplasty followed by deployment of the more flexible Enterprise stent for the treatment of complex symptomatic ICAS. METHODS: Forty-four patients on combined antiplatelet therapy and intensive risk factor management and a symptomatic 70-99% stenosis of a major intracranial artery in complex settings that was treated with balloon angioplasty and Enterprise stent deployment between July 2009 and August 2013 were enrolled. Primary outcome was occurrence of ischemic or hemorrhagic stroke or death within 30 days after intervention. Secondary outcomes included procedural success (defined as achievement of <50% immediate residual stenosis), and follow-up clinical and angiographic outcomes. RESULTS: With a procedural success rate of 100%, stenosis was reduced from 79.3 ± 8.1-14.9 ± 2.3%. Three (6.8%) ischemic and 1 (2.2%) hemorrhagic strokes occurred during the periprocedural period, with no further transient ischemic attacks or strokes in the 42 patients available at median 25.6 (range, 12-57) months follow-up. Of the 38 (86.4%) patients who underwent angiographic follow-up, 3 (6.81%) developed >50% in-stent restenosis after mean 22 months follow-up. CONCLUSION: In this retrospective, single-center experience, undersized balloon angioplasty followed by Enterprise stent deployment appears technically feasible with a relatively low rate of complications for the treatment of complex symptomatic ICAS. Prospective, multicenter, randomized controlled trials against optimal medical management are warranted.

Protective effect of resveratrol against endotoxemia-induced lung injury involves the reduction of oxidative/nitrative stress.

BACKGROUND: Resveratrol, a natural plant polyphenol, has received increasing attention because its varied bioactivities, including the inhibition of tumorigenesis, lipid modification and calorie-restriction. We aimed to investigate the effect of resveratrol on oxidative/nitrative stress in endotoxemia-associated acute lung injury. METHODS: Mice were injected with lipopolysaccharide (LPS, 5 mg/kg, ip). Resveratrol at a dose of 0.3 mg/kg was administered alone or immediately before injection of LPS. Twenty four hours later, lung tissues were collected for histopathologic examination, and determination of malondialdehyde (MDA), H2O2, reduced/oxidized glutathione (GSH/GSSG) ratio, total antioxidant capacity (T-AOC), superoxide dismutase (SOD) activity, catalase (CAT) activity, inducible nitric oxide synthase (iNOS) expression, nitric oxide (NO) and peroxynitrite production. RESULTS: Resveratrol treatment improves histopathological changes in the lung during endotoxemia. Increased oxidative stress in endotoxemic lung was reversed by resveratrol treatment, as evidenced by the decreases of pro-oxidant biomarker (MDA and H2O2), and the increases of anti-oxidant biomarkers (GSH/GSSG ratio, T-AOC, CAT and SOD activity). Treatment with resveratrol inhibited endotoxemia-induced iNOS expression and NO production. Moreover, peroxynitrite formation in endotoxemic lung was significantly attenuated after resveratrol treatment. CONCLUSIONS: Resveratrol exerts protective effects against acute endotoxemia-associated lung injury. These beneficial effects may be due to both the anti-oxidant and anti-nitrative properties of resveratrol. These findings support the potential for resveratrol as a possible pharmacological agent to reduce acute lung injury resulting from oxidative/nitrative damage.

Clinical Outcomes On Tubridge Flow Diverter in Treatmenting Intracranial Aneurysms: a Retrospective Multicenter Registry Study.

PURPOSE: In China, the application of nitinol Tubridge flow diverter (TFD) has become popular for treating intracranial aneurysms (IAs). In this study, we investigated the safety outcomes of the application of TFD for treating IAs in real-world scenarios. METHODS: We retrospectively analyzed aneurysms treated with TFD in 235 centers throughout China between April 2018 and April 2020. The primary endpoint was the event-free survival rate at 12 months, defined as the occurrence of morbidity (spontaneous rupture, intraparenchymal hemorrhage (IPH), ischemic stroke, and permanent cranial neuropathy) or death. Univariate and multivariate analyses were performed to assess the risk factors. A good outcome was defined as a modified Rankin Score (mRS) of 0-2. RESULTS: We included 1281 unruptured aneurysms treated with TFD. The overall neurological morbidity and death rates after 12 months were 5.4 and 2.8%, respectively. Ischemic strokes were the most common complication (4.2%, P < 0.001). Cranial neuropathy, IPH, and spontaneous rupture occurred in 0.3%, 0.3%, and 0.5% of aneurysms, respectively. Univariate and multivariate analyses indicated that the male gender, older age, larger aneurysm diameter, and aneurysm located on BA were the independent risk factors for neurologic events. Aneurysm located on BA was the independent risk factor for ischemic strokes. Most patients (1222) had access to the mRS, and 93.2% of them achieved good outcomes. CONCLUSION: Treatment of IAs with TFD was associated with low morbidity and mortality, most of which were ischemic events. Large posterior aneurysms might be associated with a higher complication rate. TRIAL REGISTRATION: Retrospectively registered.

Gekko Coil System for Intracranial Aneurysms Treatment in China (GREAT-China): A Prospective Randomized Controlled Open-Label Noninferiority Trial.

OBJECTIVE: This study aimed to evaluate the safety and efficacy of the Gekko coil system in treating intracranial aneurysms (IAs) in clinical practice. METHODS: A prospective multicenter randomized open-label parallel positive control noninferiority trial was conducted by 11 centers in China. Patients with a target IA were randomized 1:1 to coiling with either Gekko or Axium coils. The primary outcome was successful aneurysm occlusion at 6 months postoperative follow-up, whereas the secondary outcomes included the successful occlusion aneurysm rate in the immediate postoperative period, recanalization rate at the 6 months follow-up, and technical success and security. RESULTS: Between May 2018 and September 2020, 256 patients were enrolled and randomized. Per-protocol analysis showed that the successful aneurysm occlusion rate at 6 months was 96.08% for the Gekko coil group compared with 96.12% in the Axium coil group, with a difference of -0.04% (P = 0.877). The successful immediate aneurysm occlusion rates were 86.00% and 77.45% in the Gekko coil group and the Axium coil group, respectively, showing no significant difference between the 2 groups (P = 0.116), whereas the recanalization rates during the 6 months follow-up were 2.02% and 1.96% in the Gekko and Axium coil groups, respectively, which was not statistically significant (P = 1.000). CONCLUSIONS: This trial showed that the Gekko coil system was noninferior to the Axium coil system in terms of efficacy and safety for IA embolization. In clinical practice, the Gekko coil system can be considered safe and effective for treating patients with IA.

Comparison of staged-stent and stent-assisted coiling technique for ruptured saccular wide-necked intracranial aneurysms: Safety and efficacy based on a propensity score-matched cohort study.

Background: Application of stent-assisted coiling and FD in acute phase of ruptured wide-necked aneurysms is relatively contraindicated due to the potential risk of ischemic and hemorrhagic complications. Scheduled stenting after initial coiling has emerged as an alternative paradigm for ruptured wide-necked aneurysms. The objective of this study is to evaluate the safety and efficacy of a strategy of staged stent-assisted coiling in acutely ruptured saccular wide-necked intracranial aneurysms compared with conventional early stent-assisted coiling strategy via propensity score matching in a high-volume center. Methods: A retrospective review of patients with acutely ruptured saccular wide-necked intracranial aneurysms who underwent staged stent-assisted coiling or conventional stent-assisted coiling from November 2014 to November 2019 was performed. Perioperative procedure-related complications and clinical and angiographic follow-up outcomes were compared. Results: A total of 69 patients with staged stent-assisted coiling and 138 patients with conventional stent-assisted coiling were enrolled after 1:2 propensity score matching. The median interval time between previous coiling and later stenting was 4.0 weeks (range 3.5-7.5 weeks). No rebleeding occurred during the intervals. The rate of immediate complete occlusion was lower with initial coiling before scheduled stenting than with conventional stent-assisted coiling (21.7 vs. 60.9%), whereas comparable results were observed at follow-up (82.5 vs. 72.9%; p = 0.357). The clinical follow-up outcomes, overall procedure-related complications and procedure-related mortality between the two groups demonstrated no significant differences (P = 0.232, P = 0.089, P = 0.537, respectively). Multivariate analysis showed that modified Fisher grades (OR = 2.120, P = 0.041) were independent predictors for overall procedure-related complications and no significant predictors for hemorrhagic and ischemic complications. Conclusions: Staged stent-assisted coiling is a safe and effective treatment strategy for acutely ruptured saccular wide-necked intracranial aneurysms, with comparable complete occlusion rates, recurrence rates at follow-up and overall procedure-related complication rates compared with conventional stent-assisted coiling strategy. Staged stent-assisted coiling could be an alternative treatment option for selected ruptured intracranial aneurysms in the future.

Predictors of recurrence and complications for the endovascular treatment of unruptured middle cerebral artery aneurysm: A high-volume center experience over 12 years.

OBJECT: To assess the safety and efficacy of endovascular treatment (EVT) of unruptured middle cerebral artery (MCA) aneurysms in a retrospective cohort in a high-volume center. Predictors of complications and recurrence were determined. METHODS: Retrospectively reviewed our database of prospectively collected information for all patients with unruptured MCA aneurysms that were treated by endovascular approach from March 2008 to December 2020. A multivariate analysis was conducted to identify predictors of complications and recurrence. RESULTS: Three hundred and fifty-one patients with 370 unruptured MCA aneurysms underwent EVT were included in this study. Seventy-three aneurysms (19.7%) were treated by coiling without stent, 297 (80.3%) with stent-assisted coiling. The procedures were performed with a technical success rate of 100%. Procedure-related neurological complications occurred in 15 patients (4.1%), including 1 patient died from post-procedural stent thrombosis. Age ≥ 65 years (P = 0.039; OR = 3.400; 95% CI, 1.065-10.860) and aneurysm size ≥ 5 mm (P = 0.009; OR = 15.524; 95% CI, 1.988-121.228) were significantly associated with ischemic complications of EVT. Three hundred and six aneurysms were (87.2%) completed image follow-up (235 DSA and 71 CE-MRA). The median angiographic follow-up time were 7.0 ± 4.3 months (range from 1 to 88 months). Follow-up angiograms showed that 249 aneurysms (81.4%) were completed occluded, 29 aneurysms (9.5%) were improved, 17 aneurysms (5.6%) were stable, and 11 aneurysms (3.6%) were recanalized and 10 of them accepted retreatments. Aneurysm size ≥ 10 mm was a predictor of recanalization (P = 0.004; OR = 11.213; 95% CI, 2.127-59.098) and stent-assisted coiling can significantly reduce recanalization (P = 0.004; OR = 0.105; 95% CI, 0.023-0.479). CONCLUSIONS: EVT is a safe and effective therapeutics for unruptured MCA aneurysms management, and provides durable aneurysm occlusion rate during follow-up. Large MCA aneurysms have higher recurrence and ischemic complications risk after EVT. Stent-assisted coiling can significantly reduce the recurrence rate without increasing the risk of complications.

Stent-assisted coiling vs. coiling alone of ruptured tiny intracranial aneurysms: A contemporary cohort study in a high-volume center.

Objective: This study aims to compare the safety and efficacy of stent-assisted coiling (SAC) with those of coiling alone (CA) for the treatment of ruptured tiny intracranial aneurysms. Methods: We enrolled 245 patients with ruptured tiny intracranial aneurysms treated with coil embolization. Patients were grouped into SAC and CA groups. Baseline characteristics, periprocedural complications, clinical outcomes, and angiographic results were compared between the two groups. In addition, a subgroup analysis was conducted in the SAC group, and patients were regrouped into low-profile visualized intraluminal support (LVIS) and laser-cut groups to compare the perioperative procedure-related complications and clinical and angiographic follow-up outcomes. Results: All baseline characteristics were equivalent between the two groups except for aneurysm size and dome-to-neck aspect ratio. The rates of overall procedure-related complications, intraprocedural rupture, postoperative early rebleeding, intraprocedural thrombosis, postprocedural thrombosis, and procedure-related mortality were comparable between the two groups (P = 0.105, 0.145, 0.308, 1.000, 1.000, 0.160, respectively). Nevertheless, the rate of hemorrhagic complication in the SAC group was significantly higher (P = 0.023). The angiographic follow-up outcomes showed that the SAC group had a higher complete occlusion rate and lower recurrence rate (88.2 vs. 67.1%, 5.4 vs. 15.2%, P = 0.001). The clinical outcomes at discharge and follow-up between the two groups demonstrated no significant differences (P = 0.192 and P = 0.085, respectively). For subgroup analysis, LVIS stents were associated with a significantly higher rate of complete occlusion (P = 0.014) and a lower rate of intraprocedural rupture (p = 0.021). Moreover, multivariate analysis showed that there were no predictors for the overall, hemorrhagic, and ischemic procedure-related complications, while Raymond class was an independent predictor of retreatment (OR = 3.508, 95% CI 1.168-11.603; P = 0.029). Conclusion: Stent-assisted coiling may increase the incidence of hemorrhagic events with favorable angiographic results and comparable clinical outcomes compared with stand-alone coiling. Nevertheless, LVIS stent could improve the safety compared with lazer-cut stent. Simultaneously, considering the better long-term effect, LVIS stent-assisted coiling may be a preferable choice for ruptured tiny intracranial aneurysms.

Low profile visualized intraluminal support stent-assisted Hydrocoil embolization for acutely ruptured wide-necked intracranial aneurysms: A propensity score-matched cohort study.

PURPOSE: To compare the safety and efficacy of low profile visualized intraluminal support (LVIS) stent-assisted hydrogel coil embolization and LVIS stent-assisted bare platinum coil embolization for acutely ruptured wide-necked intracranial. METHODS: 89 patients who underwent LVIS stent-assisted hydrogel coil embolization (hydrogel coil group) and 145 patients who underwent LVIS stent-assisted bare platinum coil embolization (platinum coil group) were retrospectively reviewed after 1:2 propensity score matching (PSM). Procedure-related complications, clinical and angiographic follow-up outcomes were compared between the two groups. RESULTS: All baseline characteristics were equivalent between hydrogel coil group and platinum coil group after PSM. There were no statistical differences in immediate postoperative embolization results, clinical and angiographic follow-up outcomes between the two groups (P = 0.514, P = 0.323 and P = 0.949, respectively). Intraprocedural aneurysm rupture, intraprocedural thrombosis and postprocedural thrombosis occurred in 2 patients (2.2%, 2/89), 1 patient (1.1%, 1/89) and 1 patient (1.1%, 1/89) of the hydrogel coil group compared with 1 patient (0.7%, 1/145), 1 patient (0.7%, 1/145) and 2 patients (1.4%, 2/145) of the platinum coil group, respectively (P = 0.559, P = 1.000 and P = 1.000). Nevertheless, the rate of postprocedural aneurysm early rebleeding in the hydrogel coil group was significantly lower than that in the platinum coil group (0.0% vs 4.8%, P = 0.046). CONCLUSION: LVIS stent-assisted hydrogel coil embolization may reduce the risk of aneurysm early rebleeding compared with LVIS stent-assisted bare platinum coil embolization for the treatment of acutely ruptured wide-necked intracranial aneurysms, which implies that hydrogel coil may improve the safety of stent placement for ruptured intracranial aneurysms.

Endovascular Aneurysm Treatment with the Numen Coil Embolization System: A Prospective Randomized Controlled Open-Label Multicenter Noninferiority Trial in China.

OBJECTIVE: We investigated the safety and efficacy of the Numen coil compared with the Axium coil in the treatment of intracranial aneurysms. METHODS: Because CATCH (Coil Application Trial in China) is a prospective randomized controlled open-label noninferiority trial conducted in 10 centers across China, patients who fulfilled the inclusion and exclusion criteria were randomized 1:1 to either a test group (Numen) or a control group (Axium). The primary outcome was based on successful aneurysm occlusion at 6 months follow-up, whereas secondary outcomes included technical success, the recanalization and retreatment rates, and the rate of serious adverse events (SAEs) at 6 months and 12 months follow-up. RESULTS: Between August 2017 and December 2019, 350 patients presenting with 350 aneurysms were enrolled and randomized. Per-protocol analysis showed that the successful aneurysm occlusion rate at 6 months was 91.18% for the test group compared with 91.85% in the control group, with a difference of -0.68% (P = 0.8419), and the overall mortality during the 30-day follow-up period was 1.19% and 1.81% in the test and control group, respectively, showing no significant difference between the 2 groups (P = 0.6837), whereas the SAE incidence during the 12-month follow-up period was 12.50% and 17.47% in the test and control groups, respectively, which was not statistically significant (P = 0.2222). CONCLUSIONS: This trial showed that the Numen coil was noninferior to the Axium coil in terms of intracranial aneurysm embolization and can be considered as a safe and effective coil for treating patients with intracranial aneurysm in clinical practice.

Endovascular treatment of vertebro-vertebral arteriovenous fistula in neurofibromatosis type I: A report of two cases and literature review with a focus on endovascular treatment.

Vertebro-Vertebral arteriovenous fistula (VV-AVF) associated with neurofibromatosis Type I (NF-1) is rare. We presented two female NF-1 patients with a diagnosis of VV-AVF treated with endovascular approach. The fistula was completely obliterated with balloon assisted embolization and covered stent separately and VA patency was preserved in both cases. Reviewing the literature with a focus on endovascular treatment, endovascular occlusion of VV-AVF in NF-1 patients is safe and effective. To preserve the parent VA patency and obliterate the fistula simultaneously is challenging generally, but feasible in some cases.

Treatment delay from aneurysmal subarachnoid hemorrhage to endovascular treatment: a high-volume hospital experience.

BACKGROUND: Early treatment for patients with aneurysmal subarachnoid hemorrhage (aSAH) could significantly reduce the risk of re-bleeding and improve clinical outcomes. We assessed the different time intervals from the initial hemorrhage, admission, and endovascular treatment and identified the risk factors contributing to delay. METHODS: Between February 2017 and December 2019, 422 consecutive aSAH patients treated in a high-volume hospital were collected and reviewed. Risk factors contributing to admission delay and treatment delay were analyzed with univariate and multivariate analysis. RESULTS: One hundred twenty-two (28.9%) were admitted to the high-volume hospital at the day of symptom onset and 386 (91.5%) were treated with endovascular management at the same day of admission. The multivariate analysis found that younger age (P = 0.022, OR = 0.981, 95% CI 0.964-0.997) and good Fisher score (P = 0.002, OR = 0.420, 95% CI 0.245-0.721) were independent risk factors of admission delay. None was found to be related with treatment delay. Multivariate analysis (OR (95% CI)) showed that higher age 1.027 (1.004-1.050), poorer Fisher score 3.496 (1.993-6.135), larger aneurysmal size 1.112 (1.017-1.216), and shorter interval between onset to admission 1.845 (1.018-3.344) were independent risk factors of poorer clinical outcome. CONCLUSION: Treatment delay was mainly caused by pre-hospital delay including delayed admission and delayed transfer. Our experience showed that cerebrovascular team could provide early treatment for aSAH patients. Younger age and good Fisher score were significantly related with admission delay. However, admission delay was further significantly correlated with better clinical outcome.

Comparison of Low-Profiled Visualized Intraluminal Support Stent-Assisted Coiling and Coiling Only for Acutely Ruptured Intracranial Aneurysms: Safety and Efficacy Based on a Propensity Score-Matched Cohort Study.

BACKGROUND: Low-profiled visualized intraluminal support (LVIS) is suggested as a promising stent for complex intracranial aneurysms. However, the safety and efficacy of LVIS-assisted coiling of acutely ruptured wide-necked intracranial aneurysms have not been well reported. OBJECTIVE: To evaluate the safety and efficacy of LVIS-assisted coiling of acutely ruptured wide-necked intracranial aneurysms compared with contemporary coiling-only strategy via propensity score matching in a high-volume center. METHODS: A retrospective review of patients with acutely ruptured intracranial aneurysms who underwent LVIS stent placement or coiling only from November 2013 to October 2017 was performed. Perioperative procedure-related complications and clinical and angiographic follow-up outcomes were compared. RESULTS: All baseline characteristics were equivalent between the 2 groups except for neck size. The immediate angiographic results, procedure-related complications, procedure-related mortality, and clinical outcomes between the 2 groups demonstrated no significant differences (P = .087, P = .207, P = .685, and P = .865, respectively). The angiographic follow-up outcomes of the LVIS-assisted coiling group showed a significantly higher complete occlusion rate and lower recurrence rate compared with the coiling-only group (92.3% vs 59.9%, 4.8% vs 26.1%, P < .001). Multivariable analysis showed no significant predictors for the overall perioperative procedure-related complications, hemorrhagic complications, and ischemic complications. CONCLUSION: The LVIS stent is a safe and effective device for stent-assisted coiling of acutely ruptured wide-necked intracranial aneurysms, with comparable procedure-related complication rates, higher complete occlusion rates, and lower recurrence rates at follow-up compared with coiling only.

Outcome and Prognostic Factors of Ruptured Middle Cerebral Artery Aneurysms Treated via Endovascular Approach: A Single-Center 11-Year Experience.

OBJECTIVE: To investigate outcomes and prognostic factors of ruptured middle cerebral artery (MCA) aneurysms, treated via endovascular approach, with improving treatment materials and techniques. PATIENTS AND METHODS: A total of 185 consecutive patients, admitted with acutely ruptured MCA aneurysms and treated by endovascular methods between 2006 and 2016, were retrospectively reviewed. Their baseline characteristics, procedure-related complications, and angiographic and clinical outcomes were collected. Univariate analysis and logistic regression analysis were completed to identify any association between procedure-related complications or clinical outcomes and potential risk factors. RESULTS: Procedure-related complications occurred in 28 patients (15.1%), including aneurysm rebleeding in 7 (3.8%), hematoma expansion in 10 (5.4%), and ischemia in 13 (7.0%) (concurrent hemorrhage and ischemia in 2 patients), which resulted in morbidity/mortality of 7% and 1.4%. Final evaluations indicated that 153 patients (82.7%, 153/185) had a good outcome (modified Rankin Scale score 0-2). Among 120 (69.4%) who underwent angiographic follow-up, 89 (74.2%) were completely occluded and 20/120 (16.7%) were recanalized. Multivariate analysis of clinical outcome indicated that a high preoperative Hunt and Hess grade (IV-V), intrasylvian/intracerebral hematoma, and early period treatment (2006-2013) were associated with unfavorable outcomes. CONCLUSIONS: Endovascular treatment for patients with ruptured middle cerebral artery aneurysms may offer favorable clinical and angiographic outcomes. With the evolution of treatment materials and updated techniques, treatment complications have become less common than previously reported in literature, and clinical outcomes have been improved in recent years.

Endovascular Treatment of Ruptured Middle Cerebral Artery Aneurysms: A Single-Arm Meta-Analysis and Systematic Review.

OBJECTIVE: The use of endovascular treatment for ruptured middle cerebral artery (MCA) aneurysms, which have been more likely to be recommended for neurosurgical clipping because of the complex anatomic configuration, remains controversial. In the present study, the angiographic and clinical outcomes of endovascularly treated ruptured MCA aneurysms were systematically reviewed. METHODS: Online databases, including Cochrane, Medline, Web of Science, and Embase, were retrospectively and systematically searched. The primary outcomes were the immediate complete occlusion rate, mortality, complication-related mortality, and procedure-related complication rate. Meta-analysis was performed using a random or fixed effect model based on heterogeneity. RESULTS: A total of 14 studies with 1004 ruptured MCA aneurysms were included. The procedure-related mortality rate at discharge was 1.8% (95% confidence interval [CI], 0.9%-2.7%; I2 = 0.0%; P = 0.623). The favorable clinical outcome rate at discharge was 65.4% (95% CI, 54.8%-76.0%; I2 = 94.2%; P < 0.001) and had progressively increased to 73.2% (95% CI, 59.9%-86.5%; I2 = 80.9%; P < 0.001). The overall complication rate was 22.7% (95% CI, 15.1%-30.3%; I2 = 75.5%; P < 0.001). CONCLUSION: Endovascular treatment of MCA aneurysms was related to a high incidence of procedure-related complications but a low rate of procedure-related mortality. The overall angiographic and clinical outcomes were comparable and warrant further investigation comparing clipping versus coiling for ruptured MCA aneurysms.

Dual Stent-Assisted Coil Embolization for Intracranial Wide-Necked Bifurcation Aneurysms: A Single-Center Experience and a Systematic Review and Meta-Analysis.

OBJECTIVE: To evaluate the safety and efficacy of dual stent-assisted coiling in treatment of intracranial complex and wide-necked bifurcation aneurysms, we have reported our own center experience and performed a systematic review and meta-analysis of the reported data. METHODS: The experience in our center was reviewed and a comprehensive search of the reported data on dual stent-assisted treatment of intracranial complex and wide-necked bifurcation aneurysms was performed using the databases PubMed, Ovid EMBASE, and Ovid MEDLINE before October 1, 2018. Information was extracted regarding patient demographic data, clinical characteristics, radiographic data, treatment outcomes, complications, and clinical and angiographic follow-up data. The data were analyzed using random effects and fixed effects meta-analyses. RESULTS: Including our series of 26 patients, the data from 21 studies with 721 patients were analyzed. The procedure was technically successful in 97.6% (95% confidence interval [CI], 96.5%-98.7%). The complete occlusion rate was 61.6% (95% CI, 47.3%-75.8%) immediately after the procedure compared with 88.4% (95% CI, 84.6%-92.2%) at the last follow-up examination. The rate of periprocedural complications, total complications, procedure-related mortality was 8.8% (95% CI, 5.8%-11.9%), 9.5% (95% CI, 6.2%-12.9%), and 1.1% (95% CI, 0.3%-1.8%), respectively. The recurrence rate, retreatment rate, and good neurologic outcome rate was 3.3% (95% CI, 2.0%-4.7%), 2.7% (95% CI, 1.5%-4.0%), and 96.6% (95% CI, 95.0%-98.1%), respectively. CONCLUSIONS: The dual stent-assisted coiling technique is a feasible and effective option for the treatment of intracranial complex and wide-necked bifurcation aneurysms. It results in a relatively low rate of procedure-related complications and mortality and recurrence and a high rate of mid-term complete occlusion and good neurologic outcomes.

Risk factors for hyperperfusion-induced intracranial hemorrhage after carotid artery stenting in patients with symptomatic severe carotid stenosis evaluation.

BACKGROUND: Analyzing risk factors for hyperperfusion-induced intracranial hemorrhage (HICH) after carotid artery stenting (CAS) in patients with symptomatic severe carotid stenosis. METHODS: This study retrospectively analyzed clinical data of 210 patients, who had symptomatic severe carotid stenosis (70-99%) and received CAS treatment between June 2009 and June 2015, and evaluated the relationship of HICH with patients' clinical baseline data, imaging features, and treatment strategies. RESULTS: Seven patients (3.3%) developed HICH after CAS. The incidence of HICH among patients with near total occlusion was significantly higher than among those without (10.1% vs 0%, P<0.001). Out of the seven, five had no development of either anterior or posterior circulations, and two had no development of anterior circulation and poor development of posterior circulation. Results showed that patients with poor compensation of Willis' Circle were more likely to develop HICH compared with other patients (P<0.001). All patients received preoperative CT perfusion. TTP index was defined as the TTP ratio between the affected and contralateral side. The results showed that the TTP index was significantly different between the HICH group and non-HICH group (1.15±0.10 vs 1.30±0.15, P<0.001). An analysis of the ROC curve indicated that patients with TTP index >1.22 were more likely to develop HICH compared with other patients (sensitivity 100%, specificity 75.9%). CONCLUSIONS: Patients with severe unilateral carotid stenosis, the presence of near total occlusion, poor compensation of Willis' Circle, and preoperative TTP index>1.22, have a higher risk of developing HICH after CAS.